Adapting Trauma Focused CBT for

Individuals With Intellectual and

Developmental Disabilities

Brian Tallant, MS, LPC

1

Westside Regional Center

5901 Green Valley Circle

Los Angeles, CA 90230

April 22, 2016

This training curriculum is the property of the author and may not be reproduced without the author's written permission, unless otherwise indicated.

This training is funded by the

Mental Health Services Act

(MHSA) in partnership with the

Department of Developmental

Disabilities Services

NADD An association for individuals with developmental

disabilities and mental health needs

www.thenadd.org

2

3

http://www.nctsnet.org

Facts on Traumatic Stress and Children With

Developmental Disabilities

IDD Trauma Toolkit

The Road to Recovery: Supporting Children with

Intellectual Disabilities Who Have Experienced

Trauma

4

Aurora Mental Health Center

Collaborative program ◦ Aurora Mental Health Center ◦ Aurora Public Schools

10 children in therapeutic school 180 families served outpatient Individual, family, group therapy Psychiatric services Case management Specializing in adapted trauma treatment

Intercept Center

5

Intercept Center

6

Intercept Program Goals

Teach coping and adaptive skills so that the child

and family can function adequately

Help children in Day Treatment transition back to public school special education classrooms

Provide a structured environment for behavioral change while maintaining a supportive and challenging academic curriculum

Decrease the frequency of psychiatric hospitalizations

7

Intercept Program Goals

Stabilize children taking psychotropic medication and maintain them on a minimal effective dose

Help to empower parents so that they may assist in providing therapeutic change

Serve as a mental health representative on interdisciplinary teams and coordinate involvement of all community agencies required for the child’s treatment

Provide support services for parents and foster parents

8

Goals for today

Learn of the extremely high rates of abuse and neglect that

people with disabilities suffer, and learn of the factors that

contribute to their vulnerability.

Learn what types of adapted therapeutic interventions are

most likely to be successful for people with developmental

disabilities.

Complete a basic review of the concepts of phase oriented

trauma treatment and adaptations to this model for children

with IDD.

Learn how to incorporate caregivers and affiliated service

providers into client centered trauma treatment.

Understand what makes up therapist resilience and learn

how to develop a resilience plan

9

What is a Developmental Disability?

A legal definition, rather than a clinical diagnosis

Definition used by the US Government and basis for most states

◦ manifest before the person reaches age 22

◦ likely to continue indefinitely

◦ constitutes a substantial disability to the affected individual

◦ attributable to Intellectual disability or related conditions which include cerebral palsy, epilepsy, autism or other neurological conditions (brain damage, spinal bifida, muscular dystrophy and other sensory handicaps)

◦ Such conditions result in impairment of general intellectual functioning or adaptive behavior similar to that of mentally retarded persons

10

Clinical diagnoses that may result in

Developmental Disabilities

Cognitive or Intellectual Disability ◦ Based on IQ range of 70 or below (+ or – 5 for standard

error)

◦ Impairments in adaptive functioning in at least 2 of the following skill areas Communication

Self care

Home living

Social/Interpersonal skills

Self-direction

Work-leisure

Health

Safety

Use of community resources

Functional academics

11

Levels of ID Diagnosis

Mild: IQ 50-55 to 70

represents 70-85% of MR population

Moderate: IQ 35-40 to 50-55

represents 10% of MR population

Severe: IQ 20-25 to 35-40

represents 3-4% of MR population

Profound: IQ less than 20-25

represents 1-2% of MR population

12

Autism Spectrum Disorders

Autistic Disorder ◦ Severe impairment in social interactions & communication, and

restricted range of activities & interests

Pervasive Developmental Disorder, NOS ◦ severe and pervasive impairments in development of reciprocal

social interactions or communication skills, or when stereotyped behavior, interests, or activities are present but criteria are not met for a more specific Pervasive Developmental Disorder, schizophrenia, or personality disorder.

Asperger’s Disorder ◦ impairment in social interactions, repetitive behaviors, interests,

and activities. Typically sub-average to average IQ

(See DSM IV for diagnostic features)

13

Types of Disability

Genetic Disabilities ◦ Down’s Syndrome

◦ Fragile X Syndrome

◦ Prader-Willi Syndrome

◦ Angelman’s Syndrome

◦ William’s Syndrome

◦ Phenylketonuria (PKU)

Types of Disability

Neuromotor Disorders ◦ Cerebral Palsy

◦ Spina Bifida

◦ Traumatic Brain Injury (TBI)

Neurological Disabilities ◦ Autism Spectrum Disorders

◦ ADHD/ADD

◦ Fetal Alcohol Syndrome (FAS)

◦ Lead Poisoning

◦ Epilepsy

Types of Disability

Sensory Disabilities ◦ Involves 5 senses and their coordination

◦ Impacts kinetics and awareness of body

◦ Hypersensitivity

◦ Hyposensitivity

◦ Easily distracted

◦ Social and or emotional problems

◦ High or low activity levels

16

Prevalence of Developmental

Disabilities

Roughly 1.8% of the population of the United States.

So with a 2010 population estimate of 309 million people we estimate 5.6 million people in the US with developmental disabilities.

Trauma May Take Many Forms

• Natural disasters

• Accidents

• Invasive medical procedures

• Physical abuse

• Emotional abuse

• Sexual abuse

17

Under Reporting

• Estimated 1 in 30 instances of sexual abuse against a

person with a developmental disability are

successfully reported

• 1 in 5 for the general population

• Estimated only 3% of Sex Abuse cases are reported

for this population

18

James, 1988

Valenti-Hein and Schwartz, 1995

Higher Incidents of Abuse for

People with Any Disability

• 1.2 to 2 times more likely to suffer from

maltreatment than their nondisabled peers

• 3.4 times as likely to be neglected

• 4 times more likely to be the victims of crime

19

Sobsey, 1996

Westat, Inc., 1993; Goldson, 2002

Higher Incidents of Abuse for People with

Developmental Disabilities

• Meta-analysis shows people with developmental

disabilities suffer 2.5 to 10 times the abuse and

neglect of non-disabled peers

• More than 90% of adults reported sexual abuse

within their lifetime

• 49% of that sample reported 10 or more abusive

incidents

20

Valenti-Hein & Schwartz,1995

Abuse and Disability

In an institutional setting the risk of sexual

abuse is 2 to 4 times higher than the risk in the

community

The more severe the disability, the greater the

likelihood of abuse

21

Sobsey & Mansell,1990

Sobsey, 1994

Abuse and Disability

People with more than one disability are at

higher risk of:

◦ physical abuse

◦ sexual abuse and

◦ the severity and duration of both types of abuse are greater

22

Kendall-Tackett, 2002

Abuse and Developmental Disability

• 3 to 6% of maltreated people have a permanent

developmental disability as a result of abuse or

neglect

• Child maltreatment is a factor in 10 to 25% of all

developmental disabilities

• The vicious “two-way-street” relationship between

trauma and disability

23

Sobsey, 1994

Vulnerabilities

• Higher level of assistance from caregivers

• For longer periods of time

• For invasive daily living functions

• Higher level of stress on the family/caregivers

• People are less able to meet parental expectations

24

Charlton, Kliethermes, Tallant, Taverne, & Tishelman (2004)

Vulnerabilities

• Cognitive disability interferes with:

• The ability to predict high-risk situations

• Understand what is happening in an abusive

situation

• Barriers to reporting:

• Mobility challenges

• Restricted ability to communicate

• Not perceived as credible reporters

25

Charlton, Kliethermes, Tallant, Taverne, & Tishelman (2004)

Vulnerabilities

• Trained to be compliant to authority figures

(Valenti-Hein & Schwartz, 1995)

• 44% had a relationship with their abuser directly

related to their disability (Davis, 2004)

26

Vulnerabilities

• Increased responsiveness to attention and affection

may make them easier to manipulate.

• Less likely to be provided with general sex education

or any type of training around human sexuality.

• Caregiver’s assumption that they are not developing

sexually.

• Stigma of disability: society’s tendency to label

people who are different as less than

27

Myths

• People with developmental disabilities do not have

the same response to trauma as people in the general

population (Charlton et al., 2004)

• Developmental disabilities serve as a protective factor

against the effects of trauma (Dr. Stan Katz “expert

testimony)

• People with developmental disabilities cannot benefit

from therapy (Mansell et al., 1998)

28

Facts

• People with developmental disabilities suffer from the

same difficulties in life that the non-disabled population

encounters

• Anxiety and depression

• Grief and trauma

• Job stress, divorce, separation, etc.

29

Charlton et al., 2004; Butz et al., 2000; Nezu & Nezu, 1994

Facts

• Many different types of therapy have been found to be

effective in treating people with developmental

disabilities.

• Although it generally takes longer for people with

developmental challenges to make changes, those

changes are stable once made.

• People with developmental disabilities are less likely to

recover spontaneously from trauma without treatment.

30

31

Higher Rates of Mental Illness

Less resilience due to limited personal resources

Increased vulnerability in the home and community

Less resilience due to societal discrimination as with other minorities

Awareness of disabilities and stigma of difference

32

The Need for Adapted Treatment

People with developmental disabilities are more likely to be impacted by abuse due to a variety of factors that impair their resilience or ability to spontaneously recover their former level of functioning following an abusive incident.

Charlton et al., 2004; Burrows & Kochurka, 1995; and Mansell, Sobsey, & Moskal, 1998

33

Community Realities

Few professionals are trained to meet the needs of People with developmental disabilities

We don’t have adequate research on how best to adapt trauma treatment for this population

34

Cultural Considerations:

Disempowerment and injustices as other minorities

We are just beginning to develop evidence based adapted treatments for people with developmental disabilities

Research is not yet available on the interaction of ethnic minority status with developmental disability

35

Changing Culture of Developmental

Disabilities

The concept of disability or lack of certain desirable characteristics is interwoven throughout the definition of the population and the nature of most treatment recommendations.

The population is defined externally, by caregivers and treatment providers, rather than the people involved.

36

Changing Culture of Developmental

Disabilities

Many think of people with developmental disabilities living with their families in relative isolation or living in institutions.

As inclusion in community increases, cultural norms and expectations are developing in a variety of areas:

◦ Educational

◦ Social Vocational

◦ Residential

◦ Recreational

Other Realities

Working with this population requires ADVOCACY ◦ Funding source denials based on “non-

covered” diagnoses

◦ Over reliance on psychiatric medications as interventions

◦ Barriers to primary care increase behaviors related to medical conditions

◦ Tendency to ask “what’s wrong with them,” not “what happened to them.”

38

Dual Diagnosis Treatment and Cultural

Competency

Effective treatment requires some understanding of the culture of disability

Familiarity with healthy people who have developmental disabilities help you identify psychopathology

Stigma, lack of exposure, preconceptions, and fear are more common barriers for therapists than a lack of clinical skills

39

IDD & Trauma Assessment

40

Common characteristics of people

with developmental disabilities

Impulsivity

Poor judgment or problem solving

Low understanding of social conventions, resulting in problems with uninhibited socially inappropriate behavior

Poor understanding of society’s “unwritten” rules

Good ability to mimic behaviors around them

◦ For example, psychotic like symptoms if recently

hospitalized

41

Assessment

With children, it is important to consider not only the child’s chronological age, but more importantly, the developmental age ◦ Often the problem behavior you are being

asked to treat is developmentally appropriate and what is needed is caregiver education

42

Assessment

Problems or deficits related to a developmental disability are global and static

Psychopathology is recognized by deviations from baseline

There is often an over attribution of problems to the developmental disability

Trauma Information

• It is important that normal trauma responses not be attributed to the person’s developmental disability or pre-existing mental illness.

• People with developmental disabilities generally have the same types of symptoms following trauma that anyone else would: sleep disturbance, startle response, numbing, emotional constriction, disrupted sense of safety, shattered self-identity, etc.

• Trauma responses generally represent a change from the person’s normal level of functioning.

43

When is Trauma Treatment Needed?

• When time has passed after a trauma and the

person has not returned to their prior level of

functioning.

• When the remaining symptoms of trauma are

significantly impairing the person’s ability to

function.

• Trauma history does necessitate treatment, but

possibly just trauma informed care

44

Normal Response to Trauma: Responses that abate over time

• Loss of control during the event.

• After the event:

• Intrusion of material from the event

• Numbing

• Emotional constriction

• Intense efforts to control experiences that might elicit memories

• Dissociative splitting off of aspects of the experience

• Hypervigilance (enhanced startle response and sleep disturbance)

• Shattered sense of safety

• Disruption of self-identity 45

Trauma Symptoms: Responses that continue to be problematic long after the event

• Sleep disturbance

• Exaggerated startle response

• Numbing

• Emotional constriction

• Disrupted sense of safety

• Shattered self-identity

• Trauma responses represent a significant change from the person’s normal (global) level of functioning.

46

Complex PTSD

• Early & prolonged expose to abuse and neglect

• Overdevelopment of hypothalamus & limbic system

• Underdevelopment of frontal lobe and executive

functioning

• Lower brain weights and less fissures in the brain

• Hyper-vigilance at baseline

• Dissociative episodes under acute stress

• Aggressive behavior

• Extreme avoidance and dysregulation when triggered

47

Why Assess Trauma?

• Provides a “picture” of what is going on with the

individual

• Helps to determine

• Presenting symptoms

• Do they need treatment?

• What types of treatment are best fit

• If trauma focused treatment is indicated

• Helps in development of treatment plan

• Enables therapist to assess treatment progress

Assessment in Treatment

• Trauma assessments are not investigations

• Treatment is about a client’s perceptions not

necessarily about facts of what happened

• Assessment is an ongoing component of

treatment

• Psychoeducation of caregivers is an essential

part of ongoing assessment

Areas of Assessment

• Trauma History

• Presenting trauma and its important characteristics

• All other traumas

• Mental Health Symptoms and Behavior Problems

• History and current symptoms

• Environment

• Safety, support, individual-caregiver relationship

• System involvement with family/caregivers since abuse

• Characteristics of Trauma

• Frequency, chronicity, perpetrator/relationship,

disclosure and response

• Legal involvement

Challenges in Assessment

• Be careful of diagnostic overshadowing

• Overwhelming over attribution of symptoms to the

disability

• Sensory hypersensitivity vs. startle response

• Social withdraw/depressive symptoms vs. typical ASD

• Expressive language problems vs. dissociation

• People who have cognitive disabilities sometimes do not

have family/caregivers to serve as good historians.

• Ongoing assessment needed in treatment

Adaptations to Assessment

Be sure to include all significant caretakers—there are often several

Assess for secondary trauma due to societal or community response:

◦ Assumptions that because of the developmental disability the client has not been impacted by the trauma

◦ Assumptions that the client cannot benefit from therapy

◦ Lack of availability of appropriately adapted treatment that has resulted in significant delays in providing treatment or assistance

52

Developmental issues: Why child/adolescent tools and approaches may be more

appropriate

• Reliant on parents/caregivers for history and behavioral

observation and report

• Communication and socialization deficits can result in

developmentally “childlike” presentation of symptoms

• Repetitive play or verbalizations that have trauma

themes

• Psychological Stress or psychological reactivity to

triggers

• Inability to understand that events were traumatic

• Assessments, like treatment, should be adapted for

developmental and age appropriateness.

Assessment Tools

• Baseline Trauma Assessment (NCTSN)

• Collection of traumatic event history

• Begins desensitization process through gradual

exposure

• Assessment of severity of trauma symptoms

• UCLA-PTSD Index ©1998 Pynoos, Rodriguez,

Steinberg, Stuber, & Frederick.

• Trauma Symptom Checklist for Children ©PAR

(Psychological Assessment Resources, Inc.)

55

63

Trauma Symptom

Checklist for Children: John Briere, PhD

Psychological Assessment

Resources

http://www4.parinc.com/Product

s/Product.aspx?ProductID=TSCC

The UCLA PTSD for DSM-IV ©1998 Pynoos, Rodriguez, Steinberg, Stuber, & Frederick.

64

• The National Center for Child Traumatic Stress has a power

point that can be viewed on administering and scoring the

UCLA reaction index

(http://www.nctsnet.org/products/administration-and-

scoring-ucla-ptsd-reaction-index-dsm-iv)

• The University of California requires a licensing agreement

for the use of the scale. For assistance, contact:

UCLA PTSD Index for DSM-IV: UCLA

Trauma Psychiatry Service

300 Medical Plaza

Los Angeles, CA 90095-6968

Phone: (310) 206-8973

Email: HFinley@mednet.ucla.edu

65

66

67

Small Group Discussion

Discuss how to introduce these tools to your client (and caregiver)

Reassure them that you won’t talk about details of the trauma until skills for managing stress are developed

Why is TF-CBT a Good Model to Adapt for

People who have an IDD?

It is a strength based approach

It focuses on development of competency skills

It uses cognitive behavioral treatment techniques which are relatively easy to adapt for people at different developmental levels

It has already been structured for use across a wide range of developmental levels

68

Additional Reasons for Adaptation

One of the reasons that trauma has such a negative impact on people with developmental disabilities is their impaired resilience

TF-CBT focuses on developing skills that are associated with greater resilience

◦ Strong self-esteem

◦ Ability to self-sooth

◦ Feelings of competency to deal with challenging situations

Applicable for both single-episode trauma as well as complex post traumatic stress

69

Adapting Psychotherapy for People

with Developmental Disabilities

Slow down your speech Use language that is comprehensible to the

client Present information one item at a time Take frequent pauses during the session to

check comprehension Allow for repetition and paraphrasing Allow time for cognitive processing

70

Additional Adaptations

Use multisensory input Make specific suggestions for change Allow time to practice new skills Do not assume that information will

generalize to new situations Include multiple caregivers in various

environments

71

Caution!

The current presentation is based on Cohen, Mannarino and Deblinger’s model of Trauma Focused Cognitive Behavior Therapy (TF-CBT)

The information in this presentation is a blend of standard TF-CBT training, original thought and modification of TF-CBT material for special populations.

This work is not intended to replace standard TF-CBT training.

The material presented here should not be used by those unfamiliar with TF-CBT.

72

Training Resource

Those who wish to use this adaptation should first participate in standard TF-CBT training

A free web-based training for TF-CBT is now available at:

http://tfcbt.musc.edu/ Two day certification training with case

consultation and exam are now requirements

73

Other TF-CBT Training Resources

Cohen, J.A., Mannarino, A.P., &

Deblinger, E. (2006). Treating

Trauma and Traumatic Grief in

Children and Adolescents.

New York: The Guilford Press.

74

Format for TF-CBT

Family Therapy Model

Session is generally divided between

◦ Time with client

◦ Time with caregivers

◦ Time working with everyone together

In the non-adapted model a 90 minute session is generally used, although people with developmental disabilities may need a shorter session

Sessions always end with time to do something fun together to allow the person to re-center before leaving therapy.

75

Who Can Act as Coach?

Parent Group home staff member Teacher Advocate Any caregiver that is involved with the

client and willing to commit to regularly attending sessions with the client (even by phone)

76

Adaptations for People with

Developmental Disabilities

Be sure to include all significant caretakers—there are often several

Assess for secondary trauma due to societal or community response: ◦ Assumptions that because of the developmental disability

the client has not been impacted by the trauma

◦ Assumptions that the client cannot benefit from therapy

◦ Lack of availability of appropriately adapted treatment that has resulted in significant delays in providing assistance

77

Adaptations for People with

Developmental Disabilities

Be sure that all members of the treatment team are using the same type of language to address the trauma

Simplify training techniques to increase comprehension

Work explicitly on generalization to other environments

Allow more time for the client to learn the skills

Use more repetition

Don’t assume that the material is too complex for the client to understand

78

Components of treatment

Psychoeducation ◦ Understanding trauma and the model

◦ Address safety issues

◦ Assessment

Skills Development Trauma Narrative Trauma Processing Reintegration

79

Phases of Treatment

Assessment Address safety issues Psychoeducation Skills Development Trauma Narrative Trauma Processing Reintegration

80

Address Safety

Is the client currently in a safe environment?

What is the risk for re-traumatization?

Does the client need extra help dealing with ongoing environmental stressors? (dealing with provocative peers, teasing at school, etc.)

Are there cognitive distortions that increase the current perception of danger

81

Components of Treatment

Assessment Address safety issues Psychoeducation Skills Development Trauma Narrative Trauma Processing Reintegration

82

Psychoeducation

Provide general education to client and caregivers about the impact of trauma on normal functioning

Provide specific information about the trauma the client experienced in language that is accessible

Teach child and parent about TF-CBT phases and how treatment will progress

Risk Reduction ◦ Identify “Red Flag” situations

◦ Develop a safety plan

◦ Develop appropriate assertiveness skills

83

Psychoeducation Issues: Sexual Abuse

Basic Information

Sexual abuse is confusing

You may be confused about whether or not you’ve been abused

Sexual abuse is when someone touches or rubs your private parts without your permission

Sometimes the person asks you to touch their private parts.

The person who does this is a sex offender

The person may make you do these things by being mean and hurting you

The person may pretend it’s just a game and give you money or something you want

The person can be someone you know, like your relative or a close friend

The person could be a complete stranger

Sexual abuse is always wrong

Sexual abuse is not your fault

84

Psychoeducation Issues: Sexual Abuse

Who is sexually abused?

Sexual abuse happens to a lot of people

Anyone can be sexually abused

It happens to people of all different ages

It happens to people who are rich or poor

The important thing to remember is that being

sexually abused is not your fault

It is not about what you look like

It is not about anything that you did

It is always the perpetrator’s fault

85

Psychoeducation Issues: Sexual Abuse

Who sexually abuses?

It is hard to understand why anyone would be a sexual abuser

There are lost of reasons--Some people have sexual feelings for people who are younger or less able than they are

Most people don’t have this kind of feeling

Some people choose to sexually abuse someone else even though they know it is wrong

Some offenders even use tricks or make people scared so they can abuse them

Most offenders are men, but sometimes women sexually abuse

You can’t tell offenders by the way they look or act or dress

Some people sexually abuse others, but there are MANY more people who do not

86

Psychoeducation Issues: Sexual Abuse How do

people feel after abuse?

The feelings can be hard to understand

Sometimes the sexual touching feels good

Sometimes the sexual touching feels bad or hurts

You may like or love the person who did this to you

You may hate or be scared of the person who did this to you

You may be really mad at the person

It’s OK to have lots of different feelings about the abuse

Some people even feel like what happened is their fault

Sometimes all these feelings affect how people behave

◦ Don’t want to be alone or sleep alone

◦ Feel mad a lot and get into lots of fights

◦ Feel sad and just want to cry all the time

It really helps to talk about all of these feelings

87

Psychoeducation Issues: Sexual Abuse Why don't

people tell about being abused?

Sometimes people don’t tell anyone that they have been abuse

Sometimes it's hard for other people to understand why you didn’t tell

There are lots of reasons why people don't tell.

◦ Sometimes, the person who did the abuse says that it's 'a secret,' and ‘don’t tell anybody.’

◦ Sometimes the person makes threats and says things like 'if you tell anyone, I'll hurt you, or I'll hurt your mom.'

◦ The person who hurt you may even tell you that if you tell, no-one will believe you.

◦ Sometimes, people don't tell because they're ashamed or embarrassed or afraid that they'll get in trouble.“

It’s OK if it took you a long time to be able to tell what happened

It’s important that you are talking now and people are helping you

88

Psychoeducation Adaptations

Help caregivers understand the unique needs of children with IDD ◦ The need for structure, routine and

predictability

◦ Objectify the flight or fight response

◦ Reinforce close approximations of the positive coping skills desired

◦ Principles of functional analysis of behavior

◦ Maintain high expectations for safety, resilience and recovery

Checklist for TF-CBT

Intercept Center—Aurora Mental Health

Date

Psychoeducation

_____ Describe the model including:

Short-term, trauma focused treatment model

Phases that will be covered in treatment

_____ Discuss structure of treatment, including:

Duration of sessions

Format of sessions

Stress the importance of consistency in treatment

_____ Address the client’s sense of safety and correct any

misperceptions

_____ Baseline trauma assessment; UCLA-PTSD Index

_____ Provide psychoeducation regarding normal responses to

trauma

_____ Provide specific information regarding the specific type(s) of

trauma experienced by the client

90

91

Small Group Discussion

Discuss how to introduce these tools to your client (and caregiver)

Reassure them that you won’t talk about details of the trauma until skills for managing stress are developed

92

Practice

Pick one of the pieces of psychoeducation

information

◦ Normal response to trauma

◦ Describe TF-CBT model and phases

◦ Sexual abuse

◦ Assessment tools

Work together and role play introducing

material, making information concrete

Pick a spokesperson to share your suggestions

with the group.

Components of Treatment

Assessment Address safety issues Psychoeducation Skills Development Trauma Narrative Trauma Processing Reintegration

93

Select the skills to teach

Not every person needs every skill Introduce skills development as a time for

deciding which skills work best for you Explore what skills have been learned

previously Be sure that by the end of this phase the

person feels the ability to control symptoms in some way

94

Skills Development

Feelings Identification Personalized Relaxation Skills Positive Self-Talk Cognitive Coping ◦ Cognitive triangle

◦ Relationship between

thoughts, feelings & behavior

Thought stopping Teach caregivers language and concepts

95

Feelings Identification &

Affect Modulation

Restrict the number of different emotions that you will work with

Pick emotions that are likely to be familiar to your clients

Use lots of repetition in creative ways ◦ Role play

◦ Feelings bingo

Use visual and verbal cues—thermometer for assessing intensity of affect

Rate affect before and after use of relaxation skills

96

Use a sample list of feelings

Happy

Sad Scared

Angry Embarrassed 97

Personalized relaxation skills

Make modifications that not only address developmental, but chronological age

Cooked spaghetti or belly breathing works well with younger people, but adults may be uncomfortable with these approaches

Isometrics often work better than other types of tension/release exercises

Teach deep breathing with simplified language

Allow time for more repetitions over a longer period of time

Involve caregivers in helping with practice sessions, but avoid setting up power struggles

98

Positive self talk

Because of their concreteness, many people with developmental disabilities do not a have a clear way of discussing or understanding their own self talk

Start by developing a vocabulary

Use lots of examples related to the client’s day to day life

Don’t become frustrated if the client doesn’t get the idea right away—continue to present the information in different ways

It often works well to combine presentation of positive self-talk with cognitive coping

99

Cognitive Coping

The Cognitive Triangle:

Recognize the relationship

between:

◦ Feelings and Thoughts

◦ Thoughts and Behavior

◦ Feelings and Behavior

Understand the effect of

◦ Inaccurate thoughts

◦ Unhelpful thoughts

Thoughts

Feelings Behavior

100

Cognitive Coping

Practice a lot of different examples of how a thought might effect a feeling or action

Talk about how positive self talk has a different effect than negative self talk

Use drawings to illustrate the points that you are making verbally—white board works well for this

101

Thought stopping

The idea that they can control their thoughts is likely to be a new one

Because of their concrete approach to many things, people with developmental disabilities may view their thoughts as something that just happens, not something under their own control

As the client becomes conscious of the self talk that is occurring, it is easier to introduce the idea that you can stop a negative thought or replace it with a positive one: “Changing the channel”

102

Adaptations to Skills Development

Restrict the number of feelings you teach Build a basic vocabulary Use multisensory teaching tools Use lots of repetition in creative ways Use lots of examples that related to the

child’s everyday life Don’t become frustrated if the client

doesn’t get the idea right away—continue to present the information in different ways

103

Skills Development Date

_____ Teach feelings identification

_____ Teach a method of identifying the intensity of feelings:

numerical scale, line, arms

_____ Provide deep (belly) breathing training

_____ Teach deep muscle relaxation through analogy (cooked or

uncooked spaghetti) or progressive muscle relaxation

techniques

_____ Teach thought stopping—client has control of their

thoughts (remote control to stop and replace whatever is

“playing”)

_____ Teach positive self talk

_____ Teach the cognitive triangle—connection between

thoughts, feelings and behavior—run through a series of

scenarios, working toward more accurate or helpful

thoughts 104

Practice Session

In your groups, role play introducing one of the skills to a client.

Practice using adaption's to the model, i.e., simple language, short statements, opportunities for feedback

Share insights with your group.

105

Components of Treatment

Assessment Address safety issues Psychoeducation Skills Development Trauma Narrative Trauma Processing Reintegration

106

TF-CBT

Narrative - a verbal, written, or artistic narrative about the trauma and related experiences, and cognitive and affective processing of the trauma experiences

Chapters to Include in the

Narrative

All about me Use the baseline trauma assessment to guide

your work Some people work from the least threatening

trauma to most challenging Some people prefer to write all the trauma

components on slips of paper and to draw one at a time to work on

After all known aspects of trauma have been covered ask about what was the worst part

Don’t assume you know what was the worst part Chapter on how they entered treatment &

recovery

108

Introducing the Narrative

We are going to be talking (or writing or drawing) about the bad stuff that happened in lots of detail because we know it helps you to get better when you talk about what happened.

One way we can talk about the abuse is by making a book.

There are other ways to do this like drawing pictures, writing, typing it out on the computer, etc...

Let's start with some stuff about you and what you like to do for fun.

Can include name, age, school, job, and favorite activity.

Session format

Check in briefly with the client and caregiver regarding how the week has gone

Spend time with the client working on the narrative

Spend time with the caregiver reviewing the narrative the client has generated

Spend time doing something the client enjoys to end the session

Narrative Session Format

At the beginning of each session check in on the client’s stress level

If the level is high use skills to reduce it to the acceptable level you and client have agreed on

With the client review the narrative that was developed last time

Continue to use stress management skills as needed, checking in on stress level frequently

Add any new information that the client brings up

Go on to the next part of the trauma narrative

111

Session Format Continued

After meeting with the client spend some time alone with the caregiver

Review the information the client produced in the narrative

Help the caregiver to deal with their own emotions regarding the narrative

Discuss any distortions the caregiver is experiencing like ◦ Unwarranted self blame

◦ Unrealistic expectations of what the caregiver can do

◦ Fears that the client has been damaged forever

112

Session Format Continued

Each session should end with time to de-stress and do something fun

Depending on the client, this may be a group activity after you have talked with caregiver or it may be with the client alone

Be prepared to suggest some fun things:

◦ Origami—especially action figures like jumping frogs

◦ Walks to interesting sites

◦ Games, puzzles, puppets

◦ Basketball, catch

◦ Grooming the therapy dog

113

Sample of Chapter One:

All About Me

My name is Jeremy. I’m 20 years old. In this picture I’m standing in front my group home. I have a lot of favorite things. I like radios, Dr. Charlton, Kiwi, and my group home mother, Jane. I like to wear suit jackets. When I grow up I want to be a king. If I can’t be king then I will get a good job where I can earn lots of money. I like it here, but I would prefer a castle. Here’s the castle I would like to live in.

Beginning of Narrative:

Single incident: 18 year old male client

“On the day I got burned I woke up around 9 in the morning. I was feeling sad and that’s when I started telling everyone “I’m going to burn myself.” Then around 1:30 I poured gasoline on me.”

Complex Trauma With Multiple Components:

Trauma occurred during early childhood.

Chapter 2: One of the bad things that happened to me is getting hit a lot.

Chapter 3: When my mom first started getting a job she sent me to live with my step mom. I always got punished there.

Chapter 4: My mom would tell me to lie to the teachers and say I have strep throat so they wouldn’t know the truth that I was hit on the back with a belt and hurt really bad.

Chapter 5: Mom was in the bathtub and she asked me to get something for her. I couldn’t find it and she got out of the tub and started kicking me.

Joe

Complex Trauma With

Multiple Components

Chapter 2 – Riding the tower of doom and other rides - I am afraid of heights. I hate heights.

Chapter 3 – My older brother – I was at my mom’s house. I was watching the news, and I saw him on the news. He got arrested for something – a double homicide

Chapter 4 – Why I don’t like school – School is a prison. It’s a prison. There’s no windows except for the doors.

Chapter 5 – The Kidnapping – My dad screwed everything up he’s a loser he wants me to get back at mom. My mom says he’s crackheadish I think he’s stupid.

Narrative Adaptations for People with

Developmental Disabilities

Be creative in the ways in which the narrative is recorded

Writing may not be practical

◦ Dictate responses to the therapist

◦ Draw pictures

◦ Use a tape recorder, video or still camera

◦ Role-play, sing or dance

◦ Consider sand tray

◦ Use play that results in tangible representations

Go slowly—more time will be needed to absorb the information and to integrate the modified cognitions

Don’t be frustrated if the client returns repeatedly to inaccurate or unhelpful cognitions—repetition is necessary for learning

119

Narrating Trauma

Date

_____ Provide information about the benefits of gradual exposure

interventions

_____ Review the feelings intensity scale and decide with the

client when they want help reducing intensity

_____ Develop a signal for when help is needed to reduce feeling

intensity

_____ Decide how the trauma narrative will be developed:

pictures, writing, dance, song, etc.

_____ Begin the trauma narrative with a first chapter that describes

the client—All about Me

_____ Do a second chapter on a relatively non threatening

“trauma.” Use the baseline trauma assessment to direct

progress through the narrative.

Note additional dates spent on basic trauma narrative:

_____ _____ _____ _____ _____ _____ _____ _____ _____ 120

Practice in your small groups

Take turns being the therapist and the client as you role play introducing the narrative process to a client you may treat with this model

Discuss your ideas for presenting the material

What insights did you have about the therapist or the client’s experience

Components of Treatment

Assessment Address safety issues Psychoeducation Skills Development Trauma Narrative Trauma Processing Reintegration

122

Processing the Narrative

Review the narrative

Identify thoughts that are not helpful

Identify areas where thoughts and feelings are missing

Identify places where the client’s thoughts are accurate and be prepared to praise them.

Add to the chapter on starting therapy and the progress the child is making

Integrate components to develop positive self-identity.

123

Session format

Generally you continue with the same format you established on the narrative

Check-in

Work with the client on processing the trauma

Review with the caregiver the work the client did during the session

Do something fun to help with re-centering

Adding Thoughts and Feelings

Thoughts: ◦ I thought everyone heard me saying I was going

to burn myself and they didn’t listen.

◦ I was surprised at what happened.

◦ I didn’t expect the burns to hurt so bad.

◦ I don’t know if I realized that I might kill myself by setting myself on fire.

Feelings: I felt mad because it sounded like they didn’t care about me.

Corrections

I needed help.

I could have told my family that I was really upset and needed help.

Then I could have gotten the help I needed without the burns.

If I get upset again this is what I’m going to do.

My family will listen even if I don’t do something dramatic.

Techniques to Help With

Processing

Best Friend role play Now and then role play Responsibility pie

Best Friend Role Play

Ask the client to take on the role of his or her best friend, and the therapist takes on the role of the client. The task is to have the “best-friend” counsel the therapist/client regarding the client's understanding of the trauma.

Now and Then Role Play

The client is asked to 'go back in time' to give him or herself advice about what to do about the trauma before and/or after it happens. The therapist can either play the role of the client "then," or the client can act out both parts.

Responsibility Pie

The client is asked to draw a pie chart and assign "pieces" of various sizes to different individuals who might bear some responsibility for the trauma (e.g., the perpetrator, non-offending family members, the client). The client may assign pieces and sizes to whomever he or she wants, and the size of the piece corresponds to that person's percent of responsibility for the trauma. The therapist can then discuss the relative sizes of pie pieces with the client and use this as an exercise to help the client verbalize his or her thinking about why the trauma happened. A revised pie can be drawn if the client's thinking about responsibility changes.

Adaptations to Processing the

Narrative

Go slowly

Provide lots of support

Review skills as needed

It’s particularly important to use

◦ Cognitive triangle—how you think about the trauma effects how you feel about it

◦ Identify cognitive distortions or unhelpful thoughts

◦ Then correct them in the narrative

131

Processing Trauma

Date

_____ Work through the trauma narrative with the client adding

thoughts and feelings

_____ Assist the client in critically examining and appropriately

modifying cognitive distortions (be aware of issues

around causality or responsibility for the event)

_____ Ask the client to describe the worst moment and be sure

this is included in the narrative

132

133

Practice

In your groups discuss how best to adapt trauma processing for your clients.

Role play one of the processing techniques

Select a spokesperson Return to the full group and share

your ideas on adaptation

Components of Treatment

Assessment Address safety issues Psychoeducation Skills Development Trauma Narrative Trauma Processing Reintegration

134

Reintegration Session Format

Reintegration is generally done with caregiver and client together

Begin by

◦ Assessing the client’s readiness for this phase

◦ Assessing the caregiver’s readiness for this phase

Remind everyone about the rationale for these joint sessions

135

Reintegration Rationale

The caregiver has the opportunity to demonstrate comfort in hearing and talking about the trauma, while also modeling appropriate coping;

The client has an opportunity to share the narrative and experience a sense of pride (further reduces feelings of shame and distress associated with the trauma);

Communication about the trauma is enhanced, and misunderstandings and areas of confusion can be cleared up; and

The groundwork is laid for discussion of the trauma to continue after formal therapy is over.

◦ For clients, you should emphasize the importance of communicating openly to eliminate any possible misunderstandings,

◦ Caregivers should emphasize their desire to be helpful and supportive.

136

Reintegration Sessions

The client shares the trauma narrative they have

developed with the caregiver

The caregiver:

◦ Praises the client’s hard work

◦ Asks open-ended, non-threatening questions, (i.e., How did you decide to tell someone about what happened?)

◦ Answers the client's questions (i.e., Why is mom mad

at me because her boyfriend got in trouble? Did I do the right thing?)

137

Reintegration

Caregiver and client discuss together ◦ Lessons learned

◦ Application of those lessons

◦ Plans for the future

Caregiver and client discuss the use of affect regulation skills for other life stressors

138

Reintegration Adaptations

Be sure the client has sufficient support in all environments

Work on specific ways in which new skills can be generalized to various situations in the client’s life

139

Integrating Trauma work

Date

_____ Have the client read the whole narrative to caregiver

_____ Help the client to listen to the caregiver’s

feedback (not your fault, good job, etc)

_____ Discuss what was learned in the course of treatment

_____ Add what was learned to the end of the narrative

_____ Process termination of treatment with client

_____ Process termination of treatment with caregiver

140

Components of Treatment

Assessment Address safety issues Psychoeducation Skills Development Trauma Narrative Trauma Processing Reintegration

141

Therapist Resilience &

Vicarious Trauma

Compassion fatigue

Secondary traumatic stress

Vicarious traumatization

closely related terms which capture different aspects of the stress associated with trauma treatment

Three Terms Related to

Caregiver Stress

Examples of Compassion Fatigue

Symptoms (Pelkowitz, 1997)

Cognitive

Decreased

concentration

Apathy, rigidity

Perfectionism

Emotional

Anxiety

Numbing

Depletion

Behavioral

Hypervigilance

Social withdrawal

Expressed anger

Spiritual

Loss of faith

Anger at God

Meaning of life and

work?

Examples of Compassion Fatigue

Symptoms (Pelkowitz, 1997)

Personal relations

Decreased intimacy/sex

Intolerance, loneliness

Parental overprotection

Somatic

Hyperarousal

Reduced immunity

Aches, pains, medical

problems

Work performance

Low morale

Detachment

Fatigue

Obsession with

details

Negativity

Absenteeism

Rational Detachment (CPI)

“The ability of staff to maintain control of their

own behavior in the presence of acting-out

behavior

(Crisis Prevention Institute)

Ones ability to rationally and objectively consider

all of the factors that lead to dysregulation in order

to emotionally detach from the situation, regulate

one’s self, and manage crisis effectively

(Brian Tallant)

A Continuum of Secondary

Traumatic Stress Responses (Stamm, 1999)

Normative Pathological

stressful traumatic stress STSD

experience reaction

challenges requires reorganization

beliefs reorganization difficult

Personal Risk Factors for STS

Reactions

History of personal trauma Identification with victim Immediate stressors on therapist Low social support Low sense of control

(Baird & Kracen, 2006; Nelson-Gardness & Harris, 2003, Regehr et al., 2004)

University of Iowa: ttp://www.uiowa.edu/~nrcfcp/training/documents/PPT%20Secondary%20Trauma.pdf

Work-Related Factors

Early in career/inexperience on the job

High caseload of trauma survivors

Lack of supervision

Exposure to critical incidents

(Baird & Kracen, 2006; Nelson-Gardness & Harris, 2003, Regehr et al., 2004)

University of Iowa: http://www.uiowa.edu/~nrcfcp/training/documents/PPT%20Secondary%20Trauma.pdf

Organizational Factors

Unusually high caseloads

High administrative burden

Conflicts w/co-workers or supervisors

Climate of constant change

Excessive emphasis on cost-effectiveness, competition

Unforgiving environment (“If you can’t handle it, leave”)

(O’Brien, 2006; Regehr et al., 2004)

University of Iowa: http://www.uiowa.edu/~nrcfcp/training/documents/ PPT%20Secondary%20Trauma.pdf

Professional Quality of Life

Compassion Satisfaction

Compassion Fatigue

Burnout Secondary

Trauma

ProQOL Model for Professional

Quality of Life

Levels of Self-Care

PHYSICAL

PSYCHOLOGICAL

SPIRITUAL

Physical Self-Care

PHYSICAL

PSYCHOLOGICAL

SPIRITUAL

Physical Self-Care

Getting medical treatment when needed

Maintain a reasonably healthy diet

Getting adequate sleep

Limiting toxins to a reasonable level

Routine purposeful movement of your body

Physical Self-Care

Maintaining a healthy diet

◦ Think of the consequences

◦ Think of the example you are setting for your children

◦ Think of the example you are setting for those you hope will follow

you down the road to health

◦ See the light at the end of the tunnel

◦ Put it off indulging one more day

◦ Sever undesirable neural connections in your brain

◦ Start by having less not none

◦ Think of the money you could be saving by forgoing treats

Physical Self-Care

Maintaining a healthy diet

◦ Reward yourself with things besides food

◦ Remove temptation

◦ Stabilize blood sugar

◦ Enjoy life as opposed to food

◦ Set a goal

◦ Remove (or manage) the stressors that cause you to eat emotionally

◦ Turn off the TV!

◦ Read Shogun

◦ Consider your future health

Physical Self-Care

Routine Purposeful Movement of Your Body

◦ Good mood

◦ Increased self-esteem

◦ Restful sleep

◦ Decrease in blood-pressure

◦ Feeling in control

◦ Reduced symptoms of depression

◦ Positive distraction

◦ Development of positive coping skills

Physical Self-Care

The Mayo Clinic Suggests:

“Exercise raises the levels of certain mood-enhancing

neurotransmitters in the brain. Exercise may also boost

feeling good endorphins, release muscle tension, help

you sleep better, and reduce levels of the stress

hormone cortisol. It also increases body temperature,

which may have calming effects. All of these changes in

your mind and body can improve such symptoms as

sadness, anxiety, irritability, stress, fatigue, anger, self-

doubt and hopelessness.”

Physical Self-Care

Explore activities you enjoy alone or with others

What prevents you from doing these activities?

◦ Are you trying to be too perfect?

◦ Is depression expressing itself as a fitness obstacle?

◦ Is being obsessed with your appearance keeping you

from your goals?

Psychological Self-Care

PHYSICAL

PSYCHOLOGICAL

SPIRITUAL

Psychological Self-Care

Developing and utilizing healthy

relationships in your life

◦ Friends

◦ Family

◦ Colleagues

◦ Clergy “Allow others to experience the joy you know

comes from helping others, and accept their

caretaking”

Psychological Self-Care

Getting psychological help when you need it

◦ Overcoming stigma and fear of identifying with your

clients

◦ Importance of receiving support from someone who

does not have an emotional investment in you

◦ Use your knowledge of yourself and the industry to

select your therapist

Psychological Self-Care

Journaling

◦ Keep a record of how your life unfolds and track your patterns,

trends, and cycles.

◦ Get to know the different parts of yourself better

◦ Journaling can be valuable tool in the therapeutic process

◦ Heal yourself and your relationships

◦ Access information stored in the unconscious

◦ Explore your dreams

◦ Develop your intuition

◦ Maximize your efficiency

◦ Explore your creativity

◦ Discover the writer in yourself

Copyright 2008 The Denver Center for Crime Victims

Psychological Self-Care

Eight suggestions for satisfying journal writing

◦ Start with a meditation

◦ Date every entry

◦ Keep what you write

◦ Write naturally and don’t worry about your

penmanship

◦ Tell the complete truth faster

◦ Protect your own privacy

Copyright 2008 The Denver Center for Crime Victims

Purposeful Time Off

“An active process of considering and choosing activities

that enhance and round out your life outside of work that

allows you to feel recharged and satisfied when you return

to work.”

Creative & Expressive Arts

Drawing/Painting/Coloring

Music

Dance

Drama

Biblio/Literary/Poetry

Utilized as tools for healing for centuries

Enhances self-awareness, self-expression & self-

esteem

Express, release and let go

Exercise in calming and mindfulness

Mindfulness, Relaxation &

Meditation

Counters the effects of stress

Reduction in breathing/heartrate rates

Decrease of 20% in oxygen consumption

Lower blood levels of lactic acid

Decreased electrodural activity

The Jacobson Technique Imagery Technique

The Quieting Response

Spiritual Self-Care

PHYSICAL

PSYCHOLOGICAL

SPIRITUAL

Spiritual Self-Care

“Every single world philosophy and religion has

something to say about pain and suffering.”

“With spiritual self-care, one size does not have to fit all. Nor do

the benefits. Taking care of your spiritual side can mean being more

connected to the present moment, aware of what is important and

what is not so important in life, connected to other people in a

meaningful way, being guided by God, or a Higher Power. Basically,

being connected to a greater meaning and purpose in life. “

(2015 Dr. Gary R. McClain PhD)

Reading for Inspiration

Belonging to a spiritual

community

Wherever two or more are gathered… Joining

a church, synagogue, temple, or other spiritual

community brings you into contact with people

who share your spiritual values, who can help

you to deepen your day-to-day experience of

spirituality and provide emotional support.

Embracing compassion

Accept yourself for who you are

Celebrate your personal strengths as well as all the

evidence that you are human and not superhuman.

And then do the same for the other people in your

life. Replace judgment with acceptance. Remind

yourself: we are all in this world together.

Making your plan for

addressing compassion

fatigue and increasing

compassion satisfaction

Framework for STS management

Prevention activities

◦ (World view: guilt/responsibility issues, personal safety,

resolving one’s own traumas, etc. Health behaviors:

Sleep, nutrition, exercise, alcohol/substances)

Soothing activities

◦ (Meditation, guided imagery, pleasure reading, yoga,

reflection, hot baths, etc.)

Discharge activities

◦ (Exercise, griefwork, massage, music, body therapies,

art, yelling at hockey games, etc.)

Framework for STS management

Professional support activities

◦ (Supervision, training, reading, consultation, de-briefing,

caseload management, connecting with co-workers

around + aspects of work, etc.)

Social support activities

◦ (Friendships, socializing, family support, emotional

support, instrumental support, etc.)

Inspiration/re-charging activities

◦ (Spirituality, time w/children, vacation, time in nature,

etc.)

Online Resources

Compassion Fatigue Awareness Project

http://www.compassionfatigue.org/

Professional Quality of Life Organization

http://proqol.org/

Gift From Within

http://giftfromwithin.org/

Figley Institute

http://figleyinstitute.com/

Next Steps

Develop an Adapted Manual for TF-CBT Include detailed suggestions for adaptation of the

model at each stage of treatment Collect pilot data regarding the effectiveness of the

modifications Make changes in the adaptations as necessary Conduct randomized controlled studies to be sure

that the adapted model is effective in treating trauma in the same way as the original model

Better integrate Positive Identity Development (Dr. Karen Harvey).

179

Cultural Competency

Working with children who are developmentally disabled is more like working with typical children than it is different

Be aware of your apprehensions and biases about this population

Use your intuition and clinical skills to adapt treatment

180

Questions?

Phase Vignettes

THANK YOU!

Brian D. Tallant, LPC

Aurora Mental Health Center

Intercept Center

16905 East 2nd Ave.

Aurora, CO 80011

303-326-3747

briantallant@aumhc.org

182